Provider Demographics
NPI:1902495831
Name:GONZALEZ PUPO, YANDRY
Entity Type:Individual
Prefix:
First Name:YANDRY
Middle Name:
Last Name:GONZALEZ PUPO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15315 SW 106TH TER APT 414
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-4564
Mailing Address - Country:US
Mailing Address - Phone:305-721-6996
Mailing Address - Fax:
Practice Address - Street 1:15315 SW 106TH TER APT 414
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-4564
Practice Address - Country:US
Practice Address - Phone:305-721-6996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-122905106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician